Prospective Reviewer (preauthorisation Consultant)
Cape Town, Western Cape, South Africa
Job Description
Prospective Reviewer (Pre-Authorization Call Centre)The Prospective Reviewer role within the pre-authorization call centre, is responsible for authorizing hospital authorization requests ensuring that requirements of clinical appropriateness, medical necessity and clinical risk management are met.Key Activities:
- Authorizing hospital authorization requests by applying coding principles, medical scheme rules and benefits, and managed care policies and processes.
- Capture accurate pre-authorisation data on the system
- Educate and assist member by providing relevant clinical information to access the correct clinical benefits
- Consult member's health care professional to make informed clinical decisions and manage financial risk
- Correctly escalate complex clinical call
- Provide excellent customer service
- Address all customer complaints in alignment with policies and procedures to achieve stakeholder buy-in
- Formal nursing qualification (SANC enrolled nurse) - required
- 2 - 3 years experience in a general medical or general surgical ward, with at least 1 year at a private institution
- Minimum of 3 years in the clinical space required
- Must be computer literate
- Call centre experience advantageous
- Previous Managed Healthcare experience in a call centre environment - advantageous
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Job Detail
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Job IdJD1354261
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IndustryNot mentioned
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Total Positions1
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Job Type:Full Time
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Salary:Not mentioned
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Employment StatusPermanent
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Job LocationCape Town, Western Cape, South Africa
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EducationNot mentioned